Advances in training of the specialized human resources for health in Tanzania: the case of Muhimbili University of Health and Allied Sciences

Background Increasing the number of specialized human resources for health is paramount to attainment of the United Nations sustainable development goals. Higher learning institutions in low-and middle-income countries must address this necessity. Here, we describe the 5-years trends in accreditation of the clinical and non-clinical postgraduate (PG) programmes, student admission and graduation at the Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania, highlighting successes, challenges and opportunities for improvement. Methods This was a retrospective longitudinal study describing trends in PG training at MUHAS between 2015 and 2016 and 2019-2020. Major interventions in the reporting period included university-wide short course training programme to faculty on curricula development and initiation of online application system. Data were collected through a review of secondary data from various university records and was analyzed descriptively. Primary outcomes were the number of accredited PG programmes, number of PG applicants as well as proportions of applicants selected, applicants registered (enrolled) and students graduated, with a focus on gender and internationalization (students who are not from Tanzania). Results The number of PG programmes increased from 60 in 2015-2016 to 77 in 2019-2020, including programmes in rare fields such as cardiothoracic surgery, cardiothoracic anesthesia and critical care. The number of PG applications, selected applicants, registered applicants and PG students graduating at the university over the past five academic years had steadily increased by 79, 81, 50 and 79%, respectively. The average proportions of PG students who applied, were selected and registered as well as graduated at the university over the past five years by gender and internationalization has remained stably at 60% vs. 40% (male vs. female) and 90% vs. 10% (Tanzanian vs. international), respectively. In total, the university graduated 1348 specialized healthcare workers in the five years period, including 45 super-specialists in critical fields, through a steady increase from 200 graduates in 2015-2016 to 357 graduates in 2019-2020. Major challenges encountered include inadequate sponsorship, limited number of academic staff and limited physical infrastructure for teaching. Conclusion Despite challenges encountered, MUHAS has made significant advances over the past five years in training of specialized and super-specialized healthcare workforce by increasing the number of programmes, enrollment and graduates whilst maintaining a narrow gender gap and international relevance. MUHAS will continue to be the pillar in training of the specialized human resources for health and is thus poised to contribute to timely attainment of the health-related United Nations sustainable development goals in Tanzania and beyond, particularly within the Sub-Saharan Africa region.


Background
Building stronger health systems in paramount to attainment of the United Nations sustainable development goals (SDGs). The World Health Organization (WHO) recognizes six major health systems building blocks including human resource for health (HRH), service delivery, information, commodities, financing, leadership and governance as pivotal components for maturing health systems to reach their full potential [1][2][3]. Of these blocks, HRH is central and of paramount importance because it is the cross-cutting block [3]. Currently, there is a massive shortage of HRH around the world, estimated to be more than 4 million workers [4]. This global crisis in the health workforce is due to both absolute shortages of skilled workers as well as maldistribution of health workers, geographically and professionally [3,4]. In Sub-Sahara Africa, WHO estimates the current workforce would need to be scaled up to 140% in order to attain international health development targets [5]. Tanzania is one of the 36 countries in Sub-Saharan Africa listed among 57 countries in the world with serious crisis of the HRH [3,6]. The country's current physician-to-patients ratio is 1 physician for every 20,000 patients [7,8].
In Tanzania, this large and growing demand for HRH is apparent and is driven in part by the recent changes of disease patterns in the country such as the emergency of the new burden of non-communicable diseases (NCDs) [9][10][11]. In addition, ongoing efforts to construct new health facilities and upgrade existing ones has also increased demand for specialized health workers [12,13]. Affordability of specialized healthcare due to coverage by health insurance services such as the National Health Insurance Fund (NHIF) has also been a catalyst for health workers to pursue specialized training with the ultimate goal to self-employ once the desired specialties have been attained [14].
Ever since its founding in 1963, the Muhimbili University of Health and Allied Sciences (MUHAS) and its predecessors have produced the largest share of specialized (Master's degree level) HRH in Tanzania in fields such as internal medicine, obstetrics and gynecology, pediatrics and surgery, and was the sole producer of such specialists in the country before establishment of other medical universities from the late 1990's. To date, MUHAS is the only university in Tanzania offering training in superspecialized fields of clinical medicine (post-Master's degree level; concentrating on a narrow range of specialty [Merriam-Webster Medical Dictionary], also known as subspecialties) such as cardiology and nephrology. With the existing and growing demand, and in line with its vision, MUHAS needs to continue to play the leading role in producing an increased output of HRH, especially in the diverse specialized and super-specialized fields, without compromising quality.
In order to ensure equitable socio-economic development, higher learning institutions have the obligation to maintain narrow gender gaps by fostering unbiased enrolment and training of the specialized healthcare workforce [15]. MUHAS has addressed this imperative by putting in place the Gender Policy Guidelines since 2013, applicable to all members of the institution, inclusive of students, academic and supporting staff [16]. Likewise, in order to promote regional and international integration, the higher learning institutions must thrive to attract, enroll and support trainees from other countries which has the added benefit of fostering uniform acquisition of expertise for collective regional attainment of the SDGs [17]. Towards this goal, MUHAS has trained and continues to train specialized and super-specialized health workers from other countries, particularly from within Sub-Saharan Africa. The growth of MUHAS is therefore pivotal for timely attainment of the SDGs in Tanzania and the Sub-Saharan African region.
Since its existence, MUHAS has faced several challenges in providing specialized training to healthcare workers. Notable challenges include limited sponsorship for postgraduate students which contributes to inability of up to 35% of the selected students to register for studies, inadequate number of qualified academic staff where over half of the 313 currently available full-time academic staff are in the junior ranks of Tutorial Assistant and Assistant Lecturer, and limited physical infrastructure for teaching. Here, we describe trends in development and accreditation of postgraduate programmes, student admission and graduation at MUHAS over the past five years. We highlight successes and provide new windows into challenges and opportunities faced by academic institutions in low-and middle-income countries (LMIC) which can inform other similar efforts. and graduates whilst maintaining a narrow gender gap and international relevance. MUHAS will continue to be the pillar in training of the specialized human resources for health and is thus poised to contribute to timely attainment of the health-related United Nations sustainable development goals in Tanzania and beyond, particularly within the Sub-Saharan Africa region.

Study design
This was a retrospective longitudinal study describing trends in postgraduate degree training (Master and PhD) at MUHAS over the past five academic years (2015-2016 to 2019-2020).

Study setting
To date, MUHAS has seven academic units, comprising five Schools; ( . Besides postgraduate programs reported in this article, the University also runs 6 diploma programmes, 1 advanced diploma programme and 15 undergraduate (bachelor) degree programmes. Currently all MUHAS academic units offer postgraduate training with exception of the Institute of Allied Health Sciences. The total enrolment at the University is currently 4423 students, out of whom 1332 are postgraduate students. In the five years period under current report, the university undertook two major interventions including training of faculty on curricula development with the aim to increase the number of postgraduate programmes and initiated an online application system with the aim to increase the number of applicants for postgraduate programmes, especially from outside Tanzania.

Data sources
This study was based on review of documents (secondary data) to obtain information on accredited programmes, academic staff available for teaching, applicants for postgraduate programmes, applicants selected, applicants registered (enrolled), students who obtained sponsorship as well as students who graduated at MUHAS between 2015 and 2016 and 2019-2020. The sources of data included postgraduate admission records, records from the Students' Academic Report Information System (SARIS), graduation books, minutes of academic committee meetings and annual reports from relevant academic and administrative units.

Data analyses
Data were analyzed descriptively. Numerical data were summarized in frequencies and percentages and were presented in Tables and Figures. Outcomes of interest in this study were the trends in number of postgraduate programmes, academic staff available for teaching, admission processes (application, selection and registration), sponsorship for postgraduate programmes, together with graduation (overall as well as by gender and internationalization). In analyzing the trends in admission and graduation by gender and internationalization, the number of students in the relevant group (male, female, Tanzanian, international) was divided by total number of students in appropriate category (applied, selected, registered, graduated) and multiplied by 100, and proportions for individual academic years were presented for each group with error bars indicating standard deviation. Data were analyzed using Prism 4 (GraphPad Software, La Jolla, CA, US).  Fig. 1). In order to ensure relevance of the programmes to the labour market, the initiated programmes were demand-driven, meaning that they were created with interest and support of important stakeholders from outside of the university, including employers and professional bodies, who were consulted during the curricula development process.   Table 2). All programmes in the SOP, SON, SOD and ITM are full-time on-site.

Current list of accredited programmes by schools
Besides Master by Coursework programmes described, the University also offers research-based degree programmes in the form of Master by Research and Publications (MSc R&P) and Doctor of Philosophy (PhD). These are distinguished from coursework programmes in having intense research component culminating in a defendable thesis. Apart from the written thesis, other graduation requirements include course credits in research methodology, biostatistics, bioethics and scientific writing (15 for MSc R&P and 30 for PhD), published articles in peer-reviewed journals (2 for MSc R&P and 4 for PhD) and presentations in scientific meetings (2 for MSc R&P and 4 for PhD).

Academic staff available for teaching
Currently, the University has a total of 313 full-time academic staff. Most academic staff are aged 50 years and below (81%) and are in junior academic ranks of Tutorial Assistant and Assistant Lecturer (52%). Detailed description of the academic staff by age, gender and academic rank is provided in Table 3.

Trends in postgraduate admission and sponsorship 2015-2016 to 2019-2020 Trends in postgraduate admission
There was a steady increase in the number of applicants for postgraduate degree programmes over the past five years, from 543 in academic year 2015-2016 to 970 in 2019-2020 (79% increase). Similarly, the number of applicants selected to join the various postgraduate programmes increased over time from 470 in 2015-2016 to 853 in 2019-2020 (81% increase), which is concordant with the increase in the number of selected students who registered/enrolled at the university, from 358 in 2015-2016 to 536 in 2019-2020 (50% increase; Fig. 2A). The proportion of individuals selected for admission into the various postgraduate programmes ranged between 60 and 88% of all applicants. The proportion of individuals who registered at the University ranged between 55 and 76% of all selected applicants (Fig. 2B). On average, the proportions of male and female students who applied, were selected and registered at the University in the last  five years were 60 and 40%, respectively (Fig. 2C). Likewise, the average proportions of Tanzanians and international students who applied, were selected and registered at the University in the past five years were 90 and 10%, respectively (Fig. 2D)

Trends in postgraduate sponsorship
The The total number of students graduating at MUHAS had steadily increased over the past five years, from 200 in 2015-2016 to 357 in 2019-2020 (79% increase). The SOM and SPHSS contributed the largest number of graduates in each of the past five academic years (Fig. 3A). Mirroring the admission rates, the average proportions of male and female graduates over the past five years were approximately 60 and 40%, respectively. Similarly, the average proportions of Tanzanians and international students graduating in the past five years were approximately 90 and 10%, respectively (Fig. 3B). The Master of Medicine programmes in the School of Medicine produced the largest number of graduates in each of the past five academic years, contributing between 36.0 and 53.9% of total graduates per academic year (Table 4). Overall, the university graduated 1348 specialized healthcare workers between 2015 and 2016 and 2019-2020, including 45 super-specialists in the fields of cardiology (10), neurology (2), medical gastroenterology and hepatology (7), surgical gastroenterology and hepatology (6), neurosurgery (5), nephrology (8), hematology and blood transfusion (3), respiratory medicine (1) and urology (3).

Discussion
Increasing the number of specialized health workforce is paramount to attainment of the United Nations sustainable development goals (SDGs). Here we aimed to describe the trends in initiation of specialized programmes, enrolment and graduation at the Muhimbili University of Health and Allied Sciences (MUHAS), the premier health sciences university in Tanzania. We show that, compared to five years ago, the MUHAS has made noteworthy strides by initiating 17 new specialized and super-specialized degree programmes, increasing student enrolment by 50% and increasing the number of graduating Tanzanian and international health specialists by 79% whilst maintaining a narrow gender balance. Overall, the University graduated 1348 specialized healthcare workers MUHAS has a notable strength in the large number of specialized degree programmes in health sciences. Over the past five years, this strength has been emphasized by initiating 17 new competence-based and demanddriven programmes. The super-specialized programmes, also known as subspecialties, have been established in collaboration with partnering institutions in-country, including the Jakaya Kikwete Cardiac Institute, Muhimbili National Hospital, Muhimbili Orthopedics Institute and Ocean Road Cancer Institute, as well as universities in South Africa, Australia, United Kingdom, Germany, Sweden, Norway, Canada and USA that provided technical assistance as well as expertise in teaching as visiting scholars, adjunct faculty and through opportunities for international clinical attachments. This model has been used successfully in other countries in Sub-Saharan Africa and has proven to be effective for the transfer of skills to LMIC [18]. The increase in programmes at MUHAS reflects both the advancement in healthcare services in Tanzania and the shift of disease burden towards NCDs [10,11,19]. The newly established Master of Dentistry in Orthodontics is also one of the demanddriven programmes and very first in the East African region [20]. The curricula for other new programmes, including Master of Pharmacovigilance and Pharmacoepidemiology and MSc super-specialization in Clinical Neonatology have been developed and submitted to national accreditation body, the Tanzania Commission for Universities (TCU), which is also the regulatory authority for higher education. Developing local capacity for specialized and super-specialized medical care will have far reaching impact in advancing access to healthcare for individuals who would otherwise not be able to seek care abroad [3].
The WHO estimates that Sub-Saharan Africa would need to scale up its production of healthcare workforce by 140% in order to meet the international development targets [5]. In the space of only five years, MUHAS has risen to this challenge by increasing student enrolment by 50% and the number of graduating health specialists by 79%. In this trajectory, the University is poised to contribute significantly to increasing the number of healthcare workforce for the country and the Sub-Saharan Africa region [22]. Over the past five years, the proportion of female postgraduate students enrolling and graduating at MUHAS has been at a steady state of 40% compared to 60% for males. This level of inclusion of females in sciences is about 10 percentage points higher than would be expected in higher learning institutions across Sub-Saharan Africa [23,24]. The presence of the Gender Policy Guidelines at the university that promotes equity in higher learning is partly responsible for this success. The goal of the University is to increase the proportion of female students enrolling and graduating at the University to equal that of males. One of the strategies towards achieving this goal is to prioritize the selection of female students in scholarships whenever opportunities arise.
Besides training of Tanzanian healthcare workforce, and in line with the obligation for regional and international integration [25,26], MUHAS has also trained specialized and super-specialized healthcare workers from other countries. The proportion of international students applying, selected, registering, and graduating from the University has been at an average of 10% of all postgraduate students for the past five years. This is comparable to the level of internationalization by other universities in the region and internationally [27]. Most international students trained are from within Sub-Saharan Africa, particularly the East African region, but increasingly the University is receiving students from Southern Africa, West Africa, North Africa, the Comoros and as far as India and North America. The University has put mechanisms in place to promote admission of international students. Notably, since academic year 2018-2019, the University upgraded its postgraduate application system to online, making it easier for international students to access and apply. Further, the University has established Office of External Relations, which assists international students in navigating the admission process and immigration requirements. In the future, the University will continue to improve processes aimed at encouraging the admission, training, and graduation of specialized and super-specialized healthcare workers from other countries. Notwithstanding achievements made, there have been several challenges that were experienced over the past five years. Firstly, close to 35% of selected students in each academic year did not register due to lack of sponsor, being called back by employer due to staff shortages and other personal reasons. In addressing this challenge, the University continues to work closely with the Tanzania government through the Ministry of Health as well as Ministry of Education, Science and Technology and other stakeholders in advocating for increased sponsorship to postgraduate students. Secondly, the University has inadequate number of qualified academic staff. The University is tackling this challenge by increasing recruitment of academic staff and soliciting scholarship opportunities for training of the junior staff towards PhD. Lastly, with the expansion of programmes and enrolment, the University is currently facing limitation of physical space for teaching. In addressing this challenge, the University is working to expand the physical infrastructure including extension of the dental facility at the SOD which is underway. Furthermore, the University has acquired 3800 acres of land in Mloganzila area, Dar-es-salaam, where a new campus will be built. To date, a 571-bed state-of-the-art hospital has been built in the area and construction of the Centre of Excellence in Cardiovascular Sciences -a research and teaching facility -is near completion. Next in plan is construction of lecture halls, laboratories, student hostels, administrative buildings, library, and other supporting units.

Conclusion
Despite challenges encountered, the MUHAS has made significant advances in the past five years by increasing the number of programmes, enrolment, and graduation of specialized and super-specialized healthcare workforce for Tanzania and beyond, whilst maintaining a narrow gender gap. These milestones occurred amidst challenges of inadequate sponsorship, limited number of academic staff and limited physical infrastructure for teaching. The proposed improvements will further cement its leading role in training of the specialized and super-specialized healthcare workforce for Tanzania and Sub-Saharan Africa by enhancing the diversity of programmes, enrolment, gender equity and internationalization thus contribute positively towards timely attainment of the SDGs for Tanzania and the region.